Covid-19 FormPlease fill this form to the best of your knowledge. Name * First Name Last Name Date of Birth * MM DD YYYY Sex * Male Female Home Phone (###) ### #### Mobile Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Name * First Name Last Name Contact * (###) ### #### Questions Please fill carefully 1. Have you or anyone in your household had any of the following symptoms in the last 21 days? * Please check all that apply. sore throat runny nose cough chills loss of smell body aches for unknown reasons shortness of breath for unknown reasons loss of taste fever NONE OF THE ABOVE 2. Have you or anyone in your household been tested for COVID-19? * Yes No 3. Is any member of your household/family in quarantine pending testing outcomes for Covid 19? * Yes No 4. Is any member of your household/family in a facility being treated for Covid 19? * Yes No 5. Are you or anyone in your household a health care provider, emergency responder, defense officer, customs or immigration officer? * Yes No 6. Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19? * Yes No 7. Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19? * Yes No 8. To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19? * Yes No 9. Have you or anyone in your household travelled recently? * Yes No If you have responded Yes to any of the above, please provide details: 10. Are you vaccinated? * Yes No If Yes, which vaccine did you take? Astrazenica Sinopharm Pfizer Johnson & Johnson Date of final vaccine MM DD YYYY By submitting this form, I accept full responsibility for the answers I have provided and that the answers given are of my best knowledge. By submission of this form I digitally sign this document. * I Accept Thank you!
